INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 23-24, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Davis Archway House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on October 22, 2010.
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Plan of Correction
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs and an interview with the project/facility director, the facility failed to conduct a fire drill during sleeping hours at least once every six months.The findings include:A review of the fire drill logs was conducted on September 24, 2010. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility did not document any fire drills during sleeping hours from January 2010 to September 2010.An interview with the project/facility director on September 24, 2010 confirmed that there were no fire drills conducted during sleeping hours between January 2010 and September 2010.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs and an interview with the project/facility director, the facility failed to document the exit routes used during nine of nine fire drills, as required.The findings include:Fire drill logs were reviewed on September 24, 2010. Per regulation, the residential facility shall maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The facility failed to document the exit route used during fire drills conducted between January 2010 and September 2010. On September 24, 2010, the project/facility director was interviewed and confirmed that exit routes had not been documented on the fire drills conducted.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.26(a)(5) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(5) Working hours.
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Observations
Based on a review of personnel records and an interview with the project director, the facility failed to document annual performance evaluations as required by agency policy and regulation in four of five personnel records.The findings include:Six personnel records were reviewed on September 23-24, 2010. Five personnel records were required to include documentation of a performance evaluation. Per agency policy, performance evaluations are conducted at three months and then annually thereafter. There were no three month performance evaluations documented per agency policy in personnel records #1, 3, 5 and 6. Employee # 1 was hired on December 20, 2009. A three month performance evaluation was to be completed by March 20, 2010. There was no documentation that the three month evaluation had been completed as of September 24, 2010. Employee # 3 was hired on March 9, 2010. A three month performance evaluation was to be completed by June 9, 2010. The three month performance evaluation was not completed until July 2, 2010. Employee # 5 was hired on February 6, 2010. A three month performance evaluation was to be completed by May 6, 2010. There was no documentation that the three month evaluation had been completed as of September 24, 2010. Employee # 6 was hired on April 6, 2010. A three month performance evaluation was to be completed by July 6, 2010. There was no documentation that the three month evaluation had been completed as of September 24, 2010. An interview was conducted with the project director on September 24, 2010 at which time it was confirmed that the performance evaluations for the above mentioned employees were either not completed or were completed late.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination in two of four client records. The findings include:Seven client records were reviewed on September 24, 2010. Four client records reviewed were required to include documentation of a completed physical examination during the intake procedures. The facility failed to document a physical examination in client records # 1 and 4.Client # 1 was admitted on May 21, 2010. There was no documentation that a physical examination had been completed as of September 24, 2010. Client # 4 was admitted on September 1, 2010. There was no documentation that a physical examination had been completed as of September 24, 2010.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records and an interview with the project/facility director, the facility failed to document the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in four of four client records.The findings include:Seven client records were reviewed on September 23-24, 2010. The documentation of the type and frequency of treatment and rehabilitation services was required in the individual treatment and rehabilitation plan in four client records. The facility did not document the type and frequency of treatment and rehabilitation services in the individual treatment and rehabilitation plan in client records # 1, 2, 3 and 4. In client record #1, the client was admitted on May 21, 2010. The individual treatment and rehabilitation plan completed on May 26, 2010 did not include documentation of the type and frequency of treatment and rehabilitation services. In client record #2, the client was admitted on August 26, 2010. The individual treatment and rehabilitation plan completed on August 26, 2010 did not include documentation of the type and frequency of treatment and rehabilitation services. In client record #3, the client was admitted on July 1, 2010. The individual treatment and rehabilitation plan completed on July 1, 2010 did not include documentation of the type and frequency of treatment and rehabilitation services. In client record # 4, the client was admitted on September 1, 2010. The individual treatment and rehabilitation plan completed on September 1, 2010 did not include documentation of the type and frequency of treatment and rehabilitation services. An interview with the project/facility director on September 24, 2010 confirmed the individual treatment and rehabilitation plans did not include documentation of the type and frequency of treatment and rehabilitation services the clients were to receive.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(3) LICENSURE Support service type
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on the review of client records and an interview with the project/facility director, the facility failed to document the proposed type of support services in the individual treatment and rehabilitation plan in four of four of client records.The findings include:Seven client records were reviewed on September 23-24, 2010. The documentation of the proposed type of support services were required in the individual treatment and rehabilitation plans in four client records. The facility did not document the proposed type of support services in the individual treatment and rehabilitation plan in client records # 1, 2, 3 and 4. In client record #1, the client was admitted on May 21, 2010. The individual treatment and rehabilitation plan completed on May 26, 2010, did not include documentation of the proposed type of support services. In client record #2, the client was admitted on August 26, 2010. The individual treatment and rehabilitation plan completed on August 26, 2010, did not include documentation of the proposed type of support services. In client record #3, the client was admitted on July 1, 2010. The individual treatment and rehabilitation plan completed on July 1, 2010 did not include documentation of the proposed type of support services. In client record # 4, the client was admitted on September 1, 2010. The individual treatment and rehabilitation plan completed on September 1, 2010 did not include documentation of the support services. An interview with the project/facility director on September 24, 2010 confirmed the individual treatment and rehabilitation plans did not include documentation of the proposed type of support services.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |